Residents are provided with a variety of clinical experiences in behavioral health throughout each year. Via their continuity patients, residents receive training on how to adequately address difficult mental health issues in a 15-minute office visit. This is an extremely valuable tool that every physician uses on a daily basis. Residents also participate in chemical dependency treatment programs, short-term therapy sessions, neuropsychology consultations, and family-couples consultations. Residents become familiar with mental status exams, behavioral health interventions, family dynamics, and chemical dependency treatment. This training is provided via psychologists, clinical social workers, psychiatrists and other mental health providers.
Care of Older Adults
Residents quickly learn that taking care of the geriatric patient requires a very unique set of tools and skills. The multitude of medications, variety of chronic diseases, unique presentation of illness, decrease in physical functioning, dementia, depression, end-of-life issues, elder abuse, and family dynamics are all reasons why taking care of the elderly requires special training and practice. At least one-fourth to one-third of each resident’s continuity patients are elderly. During a three year period, residents at our program have the pleasure of getting to intimately know their geriatric patients, their families, and each patient’s special needs. Our palliative care and hospice providers are accessible and available for rotations.
Second year residents spend one month gaining experience in occupational medicine, learning about available community resources and participating in health promotion activities. This month is a hodge-podge of different valuable experiences. Residents learn about communicable diseases and their prevention at the health department, educate local elderly patients about certain physical and mental health issues at a neighborhood apartment complex and teach anatomy and physiology high school students about important adolescent health issues. Additionally, they participate in a local alcohol and chemical dependency treatment program, learn about end-of-life care while working with an oncologist at the Blue Ash Hospice Center, and adequately diagnose and treat occupational injuries while working with an occupational medicine doctor.
It is very difficult to learn dermatology from a textbook. This is why each resident spends at least 60 hours participating in the care of patients in an attending Dermatologist’s office. Residents will master diagnosis and initial treatment of common dermatologic problems, such as eczema, acne, psoriasis, rosacea, common skin cancers, warts and hives. Residents learn when to refer a patient to get higher level of care under a dermatologist. Also, residents assist with procedures and office surgery.
Elecctives are opportunities for residents to study areas of an identified deficit and/or pursue fields of personal interest in medicine not previously explored. Residents may choose from topics that include, but are not limited to, anesthesiology, advanced OB care, clinical and/or anatomic pathology, rural medicine, inner city medicine, physical medicine and rehabilitation, podiatry, infectious disease, cardiology and rheumatology, as well as other medical specialties and topics. Adequate elective months are so important during a primary care residency because residents learn priceless pearls, improve their clinical skills in each sub-specialty area, and gain a better understanding of when to refer and what tests are necessary prior to referral.
Emergency - Adult and Pediatrics
For one month, second-year residents spend time at the Bethesda North Emergency Department. Under the supervision of an attending ED physician, residents assume care of a variety of patients in the ED. In the minor care area, residents perform many procedures such as: I&D of abscesses, suturing lacerations, toenail removal, digital nerve blocks, relocation of joints, reduction of fractures, and splinting. In the major care area, residents see patients of all acuity levels. From managing patients with acute chest pain, COPD exacerbation, or acute gastroenteritis, to intubating a patient admitted with respiratory failure, or placing a central line in a trauma patient, residents truly see the whole gamut of emergency department patients. Residents can get as much or as little procedural training according to their individual interest and career goals.
Children’s Hospital Medical Center houses the nation’s busiest Pediatric Emergency Department. The one-month rotation for second-year residents is scheduled in 10-hour blocks. Residents assume all the responsibilities of a pediatric resident in the ED. Multiple preceptors and a chief resident always are available. It is during this rotation that our residents become comfortable in deciding which children are high acuity and require extensive evaluation, and which children are less ill and can be treated supportively at home. Residents become comfortable managing a multitude of common acute pediatric concerns, such as croup, pertussis, influenza, URI, transient synovitis, fractures, lacerations, septic arthritis, physical and sexual child abuse, gastroenteritis, nurse maid’s elbow and asthma exacerbations. Many of the same procedures done during adult ED month are repeated during the pediatric ED month.
This month allows first year residents the greatest opportunity to spend time in the family medicine center with their continuity patients. During this month, they devote two mornings per week and every afternoon at Bethesda’s Family Practice Clinic. The remaining mornings during this month vary, allowing different opportunities. Interns spend one morning a week doing circumcisions on newborns at Bethesda North Hospital. They also spend two mornings a week with our staff psychologist interviewing patients with mental health issues on the internal medicine service.
Second and third year residents spend three half-days per week (Monday mornings and afternoon and Tuesday mornings) seeing their continuity patients at the Family Medicine Center. Wednesday, Thursday, and Friday nights, from 8:30 p.m., to 7:00 a.m., are spent covering the Internal Medicine Service at Bethesda North Hospital. During these night shifts, residents truly gain the confidence to manage any problems that may occur with their patients overnight. These experiences are a good bridging opportunity between residency and the “real world,” because while residents have a lot of autonomy over the hospital service at night, attending physicians are always just a phone call away and eager to help. It is good practice to any resident who intends to incorporate hospital medicine into their outpatient practices after graduation.
Interns spend one to two weeks with the inpatient gynecological team made up of OB/GYN residents. Mornings are spent rounding on inpatient gynecological patients, followed by attending one or two routine gynecological surgeries per day, most of which are same-day surgeries. Afternoons on the inpatient team are spent evaluating patients presenting with gynecologic problems in the emergency room and admitting those to the hospital that require inpatient care.
The majority of the month, however, is spent learning outpatient gynecology, which is much more pertinent to the daily life of a Family Physician. Residents learn how to manage a slue of gynecologic complaints at the outpatient clinics in Warren County, including paps/pelvic/breast exam, contraception management, chronic pelvic pain, metamenorrhagia, menorrhagia, STDs, and dysmenorrhea. These clinical experiences aid residents when treating gynecologic problems that surface in their own continuity patients at the Bethesda Family Medicine Center. Monday afternoons at the OB/GYN resident colposcopy clinic are spent learning proper management of abnormal pap smears and proper techniques to perform colposcopy and cervical biopsies. Residents also attend five to six half-days of reproductive endocrine and infertility clinic learning POCS and infertility management, including witnessing infertility procedures. In addition, one to two afternoons during this month are spent learning IUD placement taught by some of our core family medicine faculty at Bethesda Family Medical Center.
Internal Medicine and Intensive Care Unit
The internal medicine team consists of two first-year residents and one second-year resident (team leader), plus pharmacy students and residents, medical students, and other team members. Under the supervision of an attending physician, the team is responsible for patients admitted through the emergency department and directly admitted to the hospital.
Our inpatient months are designed to give each resident adequate experience with a variety of patients and diseases, while optimizing teaching and learning time. Unlike other residency programs, our residents are not simply treated as “work horses.” Resident education is the main focus. This is why our internal medicine service is operated via a shift schedule. A “call shift” starts at 7 a.m. and ends at 8:30 p.m. that same day. After this time, night float covers the service, consisting of second and third year residents. Interns perform three call shifts a week, while the second year senior only performs one call shift a week. Because call shifts are no longer than 14 hours and residents are allowed a good night sleep every night, residents will be at their best potential ability to learn during teaching rounds. Also, the inpatient team carries a service of approximately 10-15 patients. The purpose of keeping the service small is to have sufficient time during rounds for evidence-based teaching, journal article review, and any questions residents may have. Our residents learn so much during these months and are ready to be team senior by the time second year comes.
Second-year residents spend one month at Bethesda North Hospital Nursery under the supervision of the Neonatologists, examining newborns with normal and abnormal conditions. Residents learn how to manage common newborn problems, such as heart murmurs, cyanosis, jaundice, poor feeding, sepsis, and failure to have a bowel movement. Residents are also invited to see newborns that need a higher level of care in the special care unit. Attendance at some high risk deliveries to hone resuscitation skills also occurs. There is no call on this rotation.
All first year residents attend a week long ALSO course in preparation for their inpatient OB rotations. ALSO courses are taught by family medicine physicians for family medicine residents. During this week, pre-natal, antepartum, intrapartum, and postpartum care are discussed, including the variety of complications that may occur during each time period.
First-year residents then spend two months on the obstetrics rotation with the Bethesda OB/GYN Residency. During these months, our residents learn the most up-to-date obstetric recommendations according to ACOG guidelines. Regardless of the level of preparation a resident has entering the rotation, he or she will leave being able to evaluate common antepartum problems in triage, such as vaginal bleeding, abdominal pain, pre-eclampsia, decreased fetal movement and rupture of membranes to name a few. They learn how to correctly interpret fetal heart tracings, and NSTs. Also, residents become competent in managing a laboring patient from start to finish, including performing artificial rupture of membranes and placing internal monitors. While some anxiety-provoking intrapartum complications may occur, such as fetal bradycardia, late decelerations, and shoulder dystocia, our residents have the peace of mind knowing that upper level OB residents are right there to teach appropriate management of each situation.
Both prenatal and postnatal care are also learned during this rotation. Interns see patients at the OB resident clinic doing prenatal and postnatal checks. Also, our residents round each morning on postnatal patients in the hospital prior to their discharge home. Thursdays are devoted entirely to lectures in OB/GYN.
The two months of dedicated training with the OB residency prepares our residents for their second and third year of residency, when they will continue to manage pregnant patients in our office and the Warren County clinic. Opportunities for continuity deliveries exist.
Each resident spends at least four to five days in the office of an ophthalmologist, learning outpatient assessment of common ophthalmologic problems. Experiences include using the slit lamp in evaluating disorders of the retina, lens, cornea and extraocular structures. This brief rotation is very valuable because many common ophthalmologic emergencies can present in very benign ways. Our residents learn how to catch these warning signs and emergently refer to ophthalmology for early intervention.
Orthopedics - Adult and Pediatric
Second-year residents spend one month at Cincinnati Children’s Hospital Medical Center rotating with pediatric orthopedic residents. While viewing surgeries is optional, residents spend most of their time seeing patients in the orthopedic clinic. Our family residents leave this month comfortable diagnosing and managing many common pediatric orthopedic problems, such as fractures, scoliosis, sever’s disease, Osgood-schlatter disease, hip dysplasia, legg-calve-perthes disease, in toeing, and slipped capital femoral epiphysis, to name a few. Residents also have four admitting shifts during this month, where they spend the night with an orthopedic resident, accompanying him or her to the ED to evaluate orthopedic problems that may present.
Third-year residents spend four weeks doing an adult Orthopedics/Sports Medicine rotation. It is during this rotation that residents master the musculoskeletal exam and learn to diagnose and manage many acute and chronic orthopedic problems. Residents learn when to order imaging, which specific imaging is needed in certain situation, and how to pick up subtle pathologic signs on the radiographic tests that were ordered. Residents also become comfortable with both lateral and medial knee injections, and shoulder injections. While not required, residents are given the option to observe orthopedic surgeries as well.
Pediatrics - Inpatient
First-year residents spend two months on the inpatient service at Cincinnati’s Children’s Hospital Medical Center, which is one of the nation’s top-ranked pediatric hospitals. In fact, CCHMC was only one of eight hospitals nationwide to rank in all 10 specialties in U.S News Best Children’s Hospitals 2010-2011. The eight specialties included cancer, diabetes and endocrinology, gastroenterology (digestive disorders), heart and heart surgery, kidney, neonatology, neurology and neurosurgery, orthopedics, pulmonology (respiratory problems), and urology. The education received during inpatient months at CCHMC is priceless. Rounds are laden with evidence-based teaching, interns are taught by senior residents during every admission, and the pediatric noon lecture series is offered daily where free catered lunch is served.
Each resident is part of a team consisting of an attending physician, senior or third-year pediatrics resident, one or two first-year pediatrics residents, a first-year Family Medicine resident from University Hospital, and two or three medical students from the University of Cincinnati. During these months, residents learn how to manage a wide variety of inpatient pediatric illnesses, including but not limited to: acute asthma exacerbation, bronchiolitis, retrotonsilar abscess, pre and post-orbital cellulitis, apneic episode, acute viral gastroenteritis, osteomyelitis, pneumonia, skin abscess with cellulitis, and fever of unknown origin.
Unique to Cincinnati Children’s Hospital is the concept of family-centered rounds. During morning rounds, the entire team enters each patient’s room to give their full assessment and plan in front of family members. Rounds are done in layman’s terms so families can medically understand what is happening with their children. Rounds keep families up-to-date with the status of their children and allow families ample time to get their important questions and concerns answered.
Pediatric Outpatient Clinics
Our residents receive outpatient pediatric training via the pediatric portion of their continuity practice at the Bethesda Family Practice Center. Approximately 25-30 percent of their continuity patients are children. However, to supplement this training and take advantage of our relationship with one of the nation’s top- ranked pediatric medical centers, second-year residents spend one month at primary medicine clinics at the Cincinnati Children’s Hospital Medical Center. Under the supervision of a pediatrician preceptor, residents gain experience in managing a variety of pediatric problems. Residents also truly master pediatric preventative medicine, including vaccinations, lead and anemia screening, behavior/developmental screening, and nutrition screening.
During the five-day radiology rotation, first-year residents review both common adult and pediatric radiologic images. The rotation concentrates on the identification of common radiological findings and observation of routine radiologic procedures. Residents work with attending radiologists and attend website lectures which hone their skills.
There is also ample time during both inpatient adult and pediatric internal medicine rotations to review all ordered images with attending radiologists.
Residents will spend one month in their sceond year and one month in the third year on the surgery rotation with a private practice physician. Minimal OR time is required during the second year rotation, and no OR time is required during the third year rotation. This rotation focuses on evaluation of surgical patients in the outpatient office setting. Here, residents perform many office procedures under the direct supervision of seasoned surgeons. Residents will master I&D of abscesses, removal of sebaceous cysts, and removal of skin lesions. Residents also learn a variation of suturing techniques. Naturally, many pre and post-op patients are seen as well.